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Review
Smartphone and tablet apps for concussion road warriors (team clinicians): a systematic review for practical users
  1. Hopin Lee1,2,3,
  2. S John Sullivan1,
  3. Anthony G Schneiders1,
  4. Osman Hassan Ahmed1,4,
  5. Arun Prasad Balasundaram1,
  6. David Williams1,
  7. Willem H Meeuwisse5,
  8. Paul McCrory6
  1. 1Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
  2. 2Neuroscience Research Australia, Sydney, Australia
  3. 3School of Medical Sciences, University of New South Wales, Sydney, Australia
  4. 4The FA Centre for Disability Football Research, St Georges Park, Burton-Upon-Trent, Burton-Upon-Trent, Staffordshire, UK
  5. 5Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  6. 6The Florey Institute of Neuroscience and Mental Health—Melbourne Brain Centre, University of Melbourne, Heidelberg, Australia
  1. Correspondence to Professor S John Sullivan, Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand; sjohn.sullivan{at}otago.ac.nz

Abstract

Background Mobile technologies are steadily replacing traditional assessment approaches for the recognition and assessment of a sports concussion. Their ease of access, while facilitating the early identification of a concussion, also raises issues regarding the content of the applications (apps) and their suitability for different user groups.

Aim To locate and review apps that assist in the recognition and assessment of a sports concussion and to assess their content with respect to that of internationally accepted best-practice instruments.

Methods A search of international app stores and of the web using key terms such as ‘concussion’, ‘sports concussion’ and variants was conducted. For those apps meeting the inclusion criteria, data were extracted on the platform, intended users and price. The content of each app was benchmarked to the Sport Concussion Assessment Tool 2 (SCAT2) and Pocket SCAT2 using a custom scoring scheme to generate a percentage compliance statistic.

Results 18 of the 155 apps identified met the inclusion criteria. Almost all (16/18) were available on an iOS platform and only five required a payment to purchase. The apps were marketed for a wide range of intended users from medical professionals to the general public. The content of the apps varied from 0% to 100% compliance with the selected standard, and ‘symptom evaluation’ components demonstrated the highest level of compliance.

Conclusions The surge in availability of apps in an unregulated market raises concerns as to the appropriateness of their content for different groups of end users. The consolidation of best-practice concussion instruments now provides a framework to inform the development of future apps.

https://doi.org/10.1136/bjsports-2013-092930

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    Introduction

    The introduction of mobile technologies in the form of smartphones and tablets has created a new landscape for innovative health delivery strategies. Since 2007, there has been a rapid growth in smartphone usage, with an estimated one billion users in 2012.1 This figure is expected to rise to two billion by 2015,2 meaning that more than one-third of the global population potentially has access to this technology.

    Collectively, this demonstrates the important role that mobile devices play in our daily lives. These devices are becoming essential not only for interpersonal communications but also as a vehicle for conducting business, and for running a wide range of specifically developed software applications (apps). In parallel with the increase in the number of smartphones and tablets has been the exponential rise in the number of apps available, often at minimal or no cost to the user. At the time of writing, there were more than 800 000 apps available from the iTunes store3 and 700 000 available from Google Play.4

    Apps are available for a wide range of purposes including uses in health, sports and medicine.5 There has been a rapid surge in the number of medical and healthcare apps with approximately 40 000 apps available for downloading for smartphones and tablets.6 Recent reports have also suggested that a large sector of the US population is using health-related apps.7 With the proliferation in the number of health-related apps and with no associated regulatory control over their content, the health practitioner and consumer are often challenged as to which app to choose and whether the content of the app is based on current best-practice information.8 ,9 With the recent release of guidelines for the regulation of medical apps by the US Food and Drug Administration (FDA) agency,10 it is likely that the regulatory control over mobile health devices will gain more public attention. However, the selection of apps that are proposed to undergo appropriate review still remains ambiguous, especially for those apps that “pose a lower risk to the public”.

    The quality of apps is dependent on the knowledge, experience and motivations of the developers and whether suitably informed health professionals are involved in the development process. Recently, there has been the emergence of a number of systematic reviews of apps conducted in a range of health areas including: orthopaedic surgery,11 pain management,12 smoking cessation,8 the self-management of asthma,9 weight loss,13 sports injury prevention14 and neurology.15 While there have been individual evaluations16 and news releases17 of specific apps for the recognition and assessment for a sports concussion, until now there have been no systematic reviews of concussion-related apps.

    With the development of recent consensus18 and position statements19 on the best-practice management of a suspected concussion, there is a content basis on which the apps can be developed. The Concussion in Sport (CIS) Group that published the 2008 Zurich guidelines have made available a free iPhone and iPad app with their assessment tools provided in an electronic format, while others have developed a range of independent apps (eg, Hockey Canada Concussion Awareness20). Collectively, the use of these apps represent an important opportunity in translating21 this essential information not only to sports medicine professionals but also to coaches, teachers, team managers and the parents of young athletes. The empowering of these individuals through the availability of concussion-related apps is a valuable step in improving the early diagnosis of a possible concussion, particularly at the community sports level where trained professionals may not be present. Paramount is the necessity for these apps to deliver current best-practice information and assessment procedures, contained in foundation documents such as the recent CIS consensus statements.18 ,22

    With the increased availability of concussion-related apps in the consumer marketplace, it is timely to review these, in order to provide the consumer and health professional with comparative information to inform their choice of app and whether the content of the app is in keeping with current international best-practice concussion management strategies. Thus, the purpose of this review was to identify and appraise smartphone/tablet apps related to the recognition and assessment of a sports concussion.

    Methods

    The key elements of a traditional systematic review methodology were used to locate all available apps relating to the assessment of a sports concussion at the time of the search (10 April 2013). In addition, a systematic approach was taken to the extraction of data and appraisal of content to reduce reviewer bias. Although the apps were all evaluated with respect to their content, no personal data were collected as part of this review. Thus, ethical approval from a recognised ethics committee was not sought.

    Inclusion criteria

    Apps were considered for inclusion in the study if they were produced in English; designed and/or marketed to be used in the recognition and assessment of concussion; available to the sports medicine professional and/or the general public and were a self-contained product. Apps were excluded if their primary function was unrelated to concussion assessment (eg, games and brain training apps), if they were essentially scoring apps for particular concussion tests, or if they were designed purely for the dissemination of information on concussion.

    Search strategy

    A systematic search strategy was used to identify smartphone apps available at the time of the search (10 April 2013). The iTunes stores (http://www.apple.com/itunes) from Australia, Canada, New Zealand, the UK and the USA were searched using the Power Search (iTunes V.10.7) function using the key words; “concussion”, “sport concussion”, “sports concussion”, “sport-concussion”, “sports-concussion”, “mild traumatic brain injury” or “mTBI”. Searches using the same strategy were also conducted in other smartphone app stores including: Google play, Blackberry App World, Ovi Store (for Nokia/Symbian brands), Windows Mobile Marketplace and Samsung apps. A supplementary search was also conducted by browsing Google with the terms; “apps”, “apps for concussion” and “apps for sports concussion” to capture any further apps which may not have been classified appropriately or were emerging into the app stores. The search strategy and selection process are presented in figure 1. The apps identified by the individual searches were pooled and duplicates removed. Where the same app was available on different platforms (iOS or Android), only one version of the app was retained for analysis, with the iOS platform being preferred. Those apps meeting the inclusion criteria were downloaded onto an Apple iPad2 (iOS 6) if they were available through the Apple iTunes store, and onto a Samsung Galaxy SII smartphone device (Android V.2.3.3) if available through Google play for further exploration and analysis. Downloading to the Apple iPad allowed the maximum flexibility in reviewing the apps.

    Figure 1
    Figure 1

    Search flow diagram.

    Data extraction

    A wide range of data about the apps was extracted from the smartphone app store's description and by reviewing the apps in operation. This information included: the purpose of the app, the date of release or update, pricing, scientific underpinnings, platform availability, intended user and whether it contained social networking site/email sharing capabilities.

    The data were extracted in a systematic manner by the principal investigator (HL) and verified by at least one other member of the research team prior to entry into an Excel spreadsheet (Microsoft 2010, Redmond, Washington, USA).

    Appraisal of the app content

    The content of each app was reviewed and appraised with reference to the content of either the Sport Concussion Assessment Tool 2 (SCAT2)23 or the Pocket SCAT224 depending on the intended user. Those apps which indicated in their description or within the product that they were for use by medical personnel were reviewed with reference to SCAT2, which was considered as the ‘gold standard’ in concussion recognition, assessment and management at the time the apps were developed. This tool has been systematically developed by an international group of experts (the CIS group) and widely disseminated internationally, cited in the research literature25 and adopted by major sporting organisations (eg, FIFA, IOC, IIHF, AFL and the IRB) and modifed and adopted by others (NFL, NHL and MLB). It was developed for use with athletes 10 years of age and over and for use by medical personnel or persons working under the supervision of such. As no formal appraisal tool was available, we developed a checklist and decision rule using an approach similar to that in a previous study evaluating the content of concussion websites26 and to that used in the content appraisal of other health-related apps.8 ,9 This checklist considered whether the seven key elements (eg, “Symptoms”, “Physical Signs”, “Balance Assessment”, etc) contained in the SCAT2 were included in the app. The checklist also contained items relating to accuracy of measurement (eg, if the symptoms were assessed on a seven-point Likert scale) and whether the SCAT2 Score (overall score) was generated, to provide a total of 10 items of interest. The content of each app was initially examined with reference to the checklist by the principal investigator (HL) and where there was doubt in the scoring, this was verified by at least one member of the research team who discussed the scoring before arriving at a joint decision. The presence of items was scored using a three-point categorical scoring system where 2=present and complete, 1=present but incomplete and 0=not included/not specified. The score of the 10 items was summed (maximum score=20) and presented as a SCAT2 compliance score (%) as an indication of how closely the contents followed that of SCAT2.

    Those apps targeted at non-medically qualified individuals such as athletic trainers, parents or coaches were assessed with respect to contents of the Pocket SCAT224 using a similar approach. The Pocket SCAT2 is a simplified version of SCAT2 developed by the same CIS group with its elements targeted at the recognition of a potential concussion by laypersons with minimal training. Thus, apps which were suggested to be appropriate for medical and non-medical user groups were reviewed against both SCAT2 and Pocket SCAT2. The data are presented in a descriptive format to allow comparisons between apps and, where applicable, as frequency counts.

    Results

    The search strategy shown in figure 1 identified 18 apps as meeting the study's inclusion criteria (table 1). Of these, 17 were identified by searching the app stores and one via the supplementary search (Google browsing) search. The major reason for apps not meeting the study's criteria included those which were not in English language, designed for gaming purposes, designed to raise awareness and/or educate about concussion, or which did not include elements of assessment. In all cases, the developers of the apps were clearly identified. Almost all apps were available on the Apple iTunes store and in some cases were offered on multiple platforms (eg, iOS and Android). All apps were compatible on both smartphone and tablet devices, except the King-Devick Concussion Screening Test V.2.3.0 app27 which was kept exclusive to the iPad. Most (13/18) were free to download, with the others ranging from US$0.99 to US$44.99. The apps were identified as being suitable for a wide range of intended user groups including: doctors, healthcare professionals, athletic trainers, parents and coaches. In some instances, apps were targeted at more than one potential user group. Generally, the apps referred to a recognised standard or provided some research evidence to support the content of the product; however, in several instances, this was absent. The potential to transmit the results was a common feature of 14 of the apps, with email being the most frequent mode. Four of the 18 apps provided the opportunity to transmit the results of the assessment to a central database hosted by the developers.

    View this table:
    Table 1

    App descriptors

    Table 2 documents the content of each of the apps which were targeted at medically qualified persons with respect to the core elements of SCAT2. The SCAT2 Compliance scores ranged from 0% to 100%. Of note here is the general lack of compliance with the SCAT2 content, with the majority of apps not including many of the core items. The content of those apps which indicated that they were for use by lay (ie, non-medical) groups is shown in table 3, where a similar spectrum of compliance to the three core elements of the Pocket SCAT224 is seen.

    View this table:
    Table 2

    Apps benchmarked to SCAT2 content

    View this table:
    Table 3

    Apps for use by laypersons benchmarked to Pocket SCAT2

    Discussion

    There has been a major international effort to consolidate the comprehensive understanding of what constitutes a concussion in a sports situation and how to manage the player to safely return to activity. Successive meetings of the CIS group have led this initiative which has resulted in the development of the concussion consensus18 ,22 ,28 ,29 as well as specific assessment tools (SCAT,29 SCAT223 and Pocket SCAT224) and, more recently, SCAT3,30 Child SCAT331 and Pocket CRT.32 Although not without criticism,33 these instruments have gone on to become the backbone of concussion assessment worldwide. The advent of smartphones and mobile technologies has created opportunities for the packaging of these and other assessment instruments into the growing market of apps and facilitating their use by a much wider audience.34

    The growth in the availability of mobile apps related to concussion recognition and assessment has been noteworthy. The first concussion-related app appeared in the marketplace in mid-2009, with 18 apps being identified in the search process for this study. It can be expected that this number will increase as new developers enter the market (eg, Concussion Toolbox,35 X2CMS36), and as apps are developed/revised to deliver SCAT 3,30 Child SCAT 331 and the Pocket CRT.32 This increased choice of apps will present the sports medicine practitioner and the consumer with the dilemma as to which app to adopt for their particular need and circumstances. It is thus important that all users are provided with a reference to some criteria beyond populist ratings or blogs from other consumers to inform their selection.

    In order to provide a reference standard, we chose SCAT223 and the Pocket SCAT224 as benchmarks for examining the content of the apps. While this decision can be debated, it does provide an internationally recognised standard with which to compare the content of each app. This is an approach analogous to that used in the examination of apps relating to smoking cessation8 and asthma self-management,9 which referenced the app content to widely accepted guidelines using coding systems similar to that used in this study. It is acknowledged that not all the apps were designed to provide a comprehensive assessment for a concussion, with some37 focusing on specific tests such as the Standardized Assessment of Concussion38 which are well established and embedded within the SCAT2 tool.

    Among those apps which provided a comprehensive approach, only the original SCAT2 Sport Concussion Assessment Tool app (developed by the CIS group) and the SCAT2 app (which was independently developed) showed a perfect compliance with the SCAT2 reference criteria adopted for this study. There was considerable variability among the content of the other apps. For instance, some apps would alter the wording of a particular item while most probably still retaining the overall objective of the item itself, or provide a reduced set of symptoms. The failure to obtain a high SCAT2 compliance score does not necessarily imply that the app does not include appropriate content for the recognition and/or assessment of a concussion; rather, it indicates that the app does not comply with the core element of the SCAT2 reference standard.

    As some apps were clearly designed to be used by non-medical personnel such as coaches or parents, these were referenced to the Pocket SCAT2 (the tool designed for this purpose). As might be expected, many of the apps met these minimum expected criteria for the recognition of a concussion and hence demonstrated a high level of compliance to the core information contained in the Pocket SCAT2; however, there was considerable variation in the content of these apps. In many instances, this subset of apps is more important as it is directed at users who may not be expected to have a sophisticated knowledge of concussion or medical training, and may rely on the app to provide prompts and an early indication of whether a player might be concussed and thus in need of a medical consultation. The public availability of apps allows anybody to download and use an app. While this may be seen as widening the opportunity to identify and manage a greater number of concussions, it also provides the potential for less qualified individuals to use such apps inappropriately. Fundamental to this point of availability is whether there is an actual need for an app. While it can be argued that they may represent nothing more than a ‘hi-tech’ way of presenting and managing information, they offer a range of functions beyond this. The use of mobile technologies is now becoming an integral component of everyday lifestyle, and thus the availability of concussion apps promotes the global access to information and facilitates documentation. Although not essential to the recognition and management of a concussion, mobile apps provide a new dimension in concussion management.

    Currently, not all health-related apps are formally regulated by the FDA or any other agency, although this is likely to change in the coming years.39 The purpose of such regulation is to provide the consumer with the confidence that the product can be used safely by the intended user. In the interim, the onus is on the developers of apps to provide the consumer with a well-documented product, and a clear indication as to the intended user group of the app. Of the apps identified in this study, it was sometimes difficult to ascertain who the app was designed to be used by; thus, these apps were evaluated both against SCAT223 and the Pocket SCAT2.24 Developers of future apps need to ensure that their product is based on a current gold standard information (such as the SCAT3,30 Pocket CRT32 and the Child SCAT331 assessment tools18); in addition, they need to be clearly targeted at the appropriate user group (eg, medical doctors; athletic trainers, physiotherapists or the general public).

    A feature of many of the apps identified in this study was the ability to transmit information, either via email or to a host database for research purposes. The ability to transmit this information via email to a doctor or a medical clinic is a useful feature; however, its usefulness is predicated on the recipient of this information having the necessary background to understand and interpret the information transmitted. A number of apps provide the option of sending the individual's data to a database for subsequent research purposes. This is of value to the database hosts and to the wider research community, although the potential security of this information and biased data retrieval is of concern. As consumers are required to make a choice between a growing number of apps, often without a sophisticated understanding of the field of concussion assessment and management, we have developed a brief consumer checklist (table 4) to assist them in making their choice. This easy-to-use guide provides a number of questions which an individual should ask as part of the process of comparing apps and making an informed choice. The checklist does not make recommendations with respect to a specific app, but rather empowers the consumer with key information to consider when choosing an app that meets their intended need. This checklist may also provide guidance to developers of sports concussion-related apps to ensure that their apps provide the necessary information to allow consumers to make an informed choice.

    View this table:
    Table 4

    Consumer checklist to assist in choosing a sports concussion app

    This study provides an initial insight into the properties and content of the apps currently available for use by professionals and consumers to aid in the determination of whether a player has been concussed. A key strength of this study was the utilisation of the key elements of a systematic review, including a systematic search strategy and transparent inclusion criteria to identify the apps to be considered. Key data on the content of each app were benchmarked to the core components of SCAT2,23 a tool which can be considered as the international reference standard in concussion assessment. This provides a recognised point of comparison for assessing the quality of the currently available concussion-related apps and those that will be released in the coming years. The core criteria used to assess the content of the apps will need to be updated in keeping with the recent publication of SCAT3.30

    The study is not without a number of limitations. While the apps were downloaded and information was extracted, no scoring of the usability of the apps was undertaken (eg, user interface and customer satisfaction). The usability is likely to be dependent on the background and experience of the individuals using the apps, and such an investigation was beyond the scope of this paper. Although the appraisal process and data extraction were conducted in an objective manner to reduce the risk of bias, the checklist developed to appraise the apps could have been further refined to include the verification of the exact details of each component of all the appraised items rather than their global inclusion. However, this approach was not deemed necessary for the purpose of this exploratory investigation.

    This study provides a comparative evaluation of the characteristics and content of apps designed to be used in the recognition and assessment of sports-related concussion. With apps being readily available to the profession and the public alike, there is a need to examine what these various apps have to offer in their content and thus whether they meet the needs of the user. Although readily available, it must be remembered that the content of SCAT2 was originally developed for use by medically trained personnel. Thus, it is important that they are not seen as a ‘do-it-yourself’ solution and that the information is used to guide a player with a suspected concussion to seek medical review.

    Conclusion

    The study provides an initial systematic review of the apps developed to recognise and assess a sports-related concussion. The ease of availability of these apps raises issues of how they might be used and by whom. It is important that the sports medicine practitioners and the public are assured that the content of the apps represents the best-practice information and is presented in an appropriate manner for the target audience. As mobile technologies become an everyday part of our lives, apps such as those reviewed here have a major role to play in safeguarding the health of sports persons via the early recognition of a possible concussion.

    What are the new findings?

    • This study provides a comparative review of mobile and tablet applications (apps) available to be downloaded and used in the recognition and assessment of a sports-related concussion.

    • There was considerable diversity in the content of the apps indicating the need for consideration as to the most appropriate app for the designated purpose.

    • This review provides the developers of new apps, or those upgrading current apps, with key information to include in their products.

    • A checklist is provided to assist consumers in making a choice as to the most appropriate app for their needs.

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    View Abstract

    Footnotes

    • Contributors OHA, HL, PM and SJS designed the study and prepared the preliminary draft. HL, APB, AGS and SJS conducted the search and data extraction. HL, SJS, PM and WHM developed the analysis strategy and criteria. All authors contributed to the analysis, drafting and approved the final version of the manuscript.

    • Competing interests PM is a coinvestigator, collaborator or consultant on grants relating to mild TBI funded by several governmental organisations. He is Co-Chair of the Australian Centre for Research into Sports Injury and its Prevention (ACRISP), which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). He has a clinical and consulting practice in general and sports neurology. He receives book royalties from McGraw-Hill and was employed in an editorial capacity by the British Medical Journal Publishing Group from 2001 to 2008. He has been reimbursed by the government, professional scientific bodies and sporting bodies for presenting research relating to mild TBI and sports-related concussion at meetings, scientific conferences and symposiums. He received consultancy fees in 2010 from Axon Sports (USA) for the development of educational material (which was not renewed) and has received support since 2001 from CogState Inc for research costs and the development of educational material. He is a cofounder and shareholder in two biomedical companies (involved in eHealth and Compression garment technologies) but does not hold any individual shares in any company related to concussion or brain injury assessment or technology. WHM has received research grant support through the University of Calgary from the Canadian Institutes of Health Research, Alberta Innovates Health Solutions, FIFA, Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute. He is Co-Chair of the Sport Injury Prevention Research Centre, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by IOC. He has a clinical and consulting practice in sport medicine at the University of Calgary Sport Medicine Centre with a focus on sport-related concussion. He has received travel funding from FIFA and the Medical Commission of the IOC. From 1998 to 2012 he was the Editor-in-Chief of the Clinical Journal of Sport Medicine and received editorial support funding from Lippincott-Wolters Kluwer. He is co-chair of the NHL/NHLPA Joint Health and Safety Committee and is a shareholder of PrivIT Inc.

    • Provenance and peer review Not commissioned; externally peer reviewed.